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� � CITY OF DIAMOND BAR EXPIRED
DEPARTMENT OF COMMUNITY&DEVELOPMENT SERVICES
� , ai66o E.c�iey�;�e s��i90 MAY 0 9 2003
(909)860.3195 Fax(909)861-3117 PRE$$
� ��'��'� BUILDING PERMIT APPLICATION FIRMLY
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� APN LOT TRACT D TE � � [� TMPE OCC
p OWNE��"^CG�S G �Fd�% CONST. GROUP
p ADDRESS ��� ZONING SETBACKS
Z CITY �• ZIP TEL.� �^ �7 FRONT RW ❑
g APPLICANT TEL. REAR ❑
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Q ADDRESS PROPOSED USE
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� DESIGNER NO.DWEL. NO. NO.
a ADDRESS UNITS STORIES BEDROOMS
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� DESCRIPTION SQ.FT. FACTOR PSF ADJ.AREANALUATION
Q OWNER-BUILDER DECLARATION SFR/ADD/REM
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� 1 HEREBV AFFlRM UNDER PEIULTV OF PERNRY THAT I AM EXEMP7 FROM THE CONTRACTORS LI- GefHJO/CBfpOR
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U COUNTYWHtpIREIX1IRESAPEHMRTOCONSTRUCT,ALTEf�IMPROVE,DEMOLISH,ORREPAIRMlYSTRUC- W P01t0/DBCk
TURE,PRIDR TO RS ISSUANCE,AL50 REOUIRES THE APPLICANT FOR SUCH PERMIT TO FI�E A SIGNED
w STATEMENT THAT HE OR SHE IS LICENSED PURSUANT TO THE PROVISIONS OF THE CONTMCTORS LI- w
� CENSE UW(CHAPTER i(COMMENCINO WITH SECTION 7a00)OF DIVISqH 3 OF THE BUSINESS AND PR0. � PooUSpa �
FESSqNSCODEJOHTHATNEORSHE15E7(EMPT7HEREFROMANDTHEBASISFORTHEALLEOEDEXEMP- (�
TION.ANV VIOUTION OF SECTION 70.91.6 0V ANV APPLICANT FOR A PERMIT SU&IEC7S THE APPLICAN7 T0 Z Re-Raof
� ACML PENALT'OF NOT MORE TNAN FNE HUNORED DOLURS(i5o0).j: �
� ❑I,ASOWNEROFTHEPROPERTY,ORMYEMPLOVEESWITHWAGESASTHEIRSOLECOMPENSA710N, � COrtIR1BfCl81 �
VALL DO THE WOW(AND THE STRUCNRE IS NOT.INTENDED OR OFFERED FOR SALE(SEC.70��,BU51- J
� NESS ANO PROFESSIONS CODE:THE CONTRACTORS LICENSE UW DOES NOT A7PLV TO AN OWNER OF �
PROPEHTY N710 BURDS OR IMPROVES THEHEON,AND NMO DOES SUqi WORK HIMSELF OR HERSELF OR
(C TNiqUGHHISORHEROWNEAIPLOVEES,PROVIDED7HATSUCFIIMPROVEMENTSARENOTINTENDEDOR m �
QOFFERmFORSALEIF,IiOWEVERTMEBUILDINOORIMPROVEMENTISSOLDWITHINONEYEAROFCOMPLE-
Z �'TqN,THE OMMER�UILDER NALL HAVE THE BURDEN OF PROVING THAT HE OR SHE OID NOT BUILD OR
� IMPROVE FOR THE PURPOSE OF SALE}
W ❑I.ASOM?IEROFTHEPROPEHfV,AMEXCLUSIVELYCONTRACTM�N7THLICENSEDCONTRACTORS
� TO CONSTRUCT THE PRO.IECT(SEC.70/4,BUSINESS AND PROFESSIONS CODE:7HE CONTMCTORS LI- V81U8liOf1 ADJ.AREA
W CENSE UW DOES NOTAPPLY TOAN OYMER OF A PROPER7V NR10 BUILDS OR IMPROVES 7HEREON,AND
� WIpCOMRACTSf-0RSUCHPRQIECTSWITIACONTRACTOR(S)LICENSEDPURSUAHTTOTHECOHiRAG pUANTITY DESCRIPTION FEE
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u" DATE OWNER F"'
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�Q LICENSED CONTRACTORS DECLARATION w
[C I HEREBY AFFIfUI UNDER PENALTV OF PE0.IUHV THAT I AM LICENSED UNDER PROVISIONS OF CHAPTER �
d G(COAIMENCIH(i WRH SECTION 7000)OF OMSION 3 OF 7HE BUSINESS AND PROFESSIONS CODE.AN� Z
MY LICENSE IS IN FULL FORCE AND EFFECT. �
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� LICENSE CLASS � LIC.NO. � � 4 r L �
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� WORKERS'COMPENSATION DECLARATION Q � v � '
� I HEREBY AFFIRM UNDER PENALTY OF PERIUHY ONE OFTHE FOLLAWING DECURATIONS: � �
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� _I HAVE AND WILI MAINTAIN A CERfIFIG1TE OF CONSENT TO SELF-INSURE FOR WORKERS' 2
COMPENSATION.AS PROVIOED BY SEC710N 370o OF 7HE LABOR COOE,FOR THE PERWRMANCE U
Q O�AIE WORK FOR WHICH 7HIS PERMIT IS ISSUED. �
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��I HAVE AND WILL MAINTAIN WORKE�S'COMPENSATION INSURANCE,AS REOUIRED BV SECTION
Q 3700 OF THE LABOR ODDE,FOR THE PERFORMANCE OF THE WORK FOR WHIp1 THIS PERMIT IS
ISSUED.MY KE 'COMPENSATION 1 UP CE CA��RqC►�.R,,Ae.ND POLICY NUMBER ARE: CONSTRUCTION
jCARRIER " �� PLAN REVIEW
� POLICY NUMBER NL_ _ ���,-<_ _ ELECTRIC
� (I}LLSSECTIONN�NDTBEOOApLEfmOFTFEPEPo�TiSFORONEHIRiXiED00U�(5100)ORLESS} PLUMBING
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Z I CERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH 7Fi15 PERMIT IS ISSUEO,I MECHANICAI � v
(} SHACC NOT EMPLOY ANV PERSON�N ANY MANNER SO AS TO BECAME SU&IECT TO THE
Uj WORKERS'COMPENSATION LAWS OF CALIFORNIA NdD AGREE THAT IF I SHOUlO BECAME INSPECTION FEE
SU&IECT TO THE WORKERS'COMPENSATION PROVISIONS OF SECTION 37o00F 7HE LABOH
S CADE,1� �ALL FORTHWITH CAMPLV WIT�1 TyO�OVI IONS. � ISSUANCE �,���
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p DATE: � L APPLICANT: ,
J WARNINO:FAILURE TO SECURE WORKERS'COMPENSATION CAVERAGE IS UNUVIFUL,AND SHALL BE ENERGY P/C
�y SU&IECTANEMPLOVERTOCRIMINALPENALTIESANDCIVILFINESUPTOONEHUNDRED7HOUSAND ENERGYPERMIT
DOLLARS(StaO,000).IN AODITON TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN
� SECTqN 3708 OF hiE LABOR CODE,INTEREST,AND ARORNEYS FEES. RETENTION FEE:
d CONSTRUCTION LENDING AGENCY PRE-ALT FEE:
� I HEREBV AFFIRM UNDEF PENAL7Y OF PERIURV iHA77HERE IS A CONSTRUCTION LENDING AGENCV
d FOR THE PERFORMANCE OF THE WOFiK FOR WHICH THIS PEHMIT IS ISSUED(SEC.30Y7,CIV,C.). w- � p ,
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w LENDER'S NAME 1 �I
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� ICERTIFYTHATIHAVEREADTHISAPPLICATIONANDSTATETHAT7HEABOVEINFORMATIONISCARHECT. TOTAL FEES �� '•��
W I AOREE TO COMPLV N7TH ALL CT'AND COUNTV ORDINANCES AND STATE UWS REUTINO TO BUILDING '
� CONSTRUCTION,AND HEREBY AUh10RRE REPRESENTATIVES OF THIS ODUNTY TO ENTER UPON THE -
ZABOVE-MENTIONED PROPERTY FOR INSPECTION PURPOSES. COMMENTS ��
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PERMITTEE NAME(P INn
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� SIONAlURE PE ITTEE DATE
� RECPT.NO. PAID BY VALIDATION
WHITE—Department Copy,YELLOW—Finance Copy,PINK—Assessor Copy,GOLDENRO�File Copy,GREEN—Applivant's Copy
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SLAB GRADE FIREPLACE FOUNDATION '
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WATER SERVICE MID HT. BOND BEAM ' �
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FRAMINGNENTILIATION FINAL BOND BEAM
ROOF COVER PRE-GRADING
ROUGH HEATING BENCHING
ROUGH ELECTRIC ROUGH GRADING
ROUGH PLUIVIBING FINISH GRADING
SHOWER/TUB TEST POOL ELECTRIC
EXT. LATH/SIDING POOL FENCING
WALL INSULATION POOL FINAL
CEILING INSULATION OFF SITE IMPS.
DRYWALL NAILING DEDICATIONS
SEWER FINAL ENG.
SEPTIC TAMK LANDSCAPE/IRRIG.
SEEP PIT/L..L. ON SITE IMPS. - �
GAS AIR TEST FINAL ZONING
FINA�CONST. FIRE QEPT. FINAL
FINAL HEATING HEALTH DEPT. FINAL �
FIPlAL EIECTRIC DEV, FEES PAID
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